Provider Demographics
NPI:1033240684
Name:CHAPMAN, JACK CHANDLEY (PSGT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CHANDLEY
Last Name:CHAPMAN
Suffix:
Gender:M
Credentials:PSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 ANDREA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5214
Mailing Address - Country:US
Mailing Address - Phone:706-366-1479
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5647
Practice Address - Country:US
Practice Address - Phone:888-884-9493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2472E0500X2472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG